Challenging Dogma - Spring 2008

...Using social sciences to improve the practice of public health

Wednesday, April 16, 2008

Is insurance the answer? A critique of the efficacy of the individual insurance mandate in promoting positive health outcomes for all – Katie Stone

The latest trend in comprehensive insurance is the individual insurance mandate, a legislative policy which forces individuals to obtain insurance. If they do not comply, they are faced with penalties [1]. As a public health intervention, the individual insurance mandate fails to adequately address the diverse reasons people fail to seek needed medical care, instead choosing to believe that insurance status is a direct predictor of health outcomes. Unfortunately, before insurance status can lead to improved outcomes, access to care must be made more equitable. By addressing problems of affordability, cultural competence, and community infrastructure, access would be expanded and the individual mandate would become a far more effective tool for improving people’s health.

The individual insurance mandate, pioneered in the U.S. by the Commonwealth of Massachusetts (MA), is a legislative decision to confer individual responsibility for obtaining health insurance on residents of the Commonwealth of Massachusetts. Enacted in 2006 as part of Chapter 58 of the Acts of 2006, this mandate requires Massachusetts residents eighteen and older to purchase health insurance and includes provisions to help residents obtain this coverage; should residents fail to purchase insurance, they face penalties on their state income tax [2]. To date, legislators have enacted a series of laws (collectively called the Health Care Reform Acts) that aim to increase the number of insured MA residents (and therefore improve their health status) by loosening income restrictions for Medicaid eligibility and enacting employer mandates which enforce tax penalties on employers who do not offer their employees coverage. While legislators allow that the Acts aim to cover 95%, rather than 100%, of uninsured residents within the next three years, this number will still be hard to achieve, as they may not have fully considered the reasons residents lack insurance. By relying heavily on the health belief model to plan their intervention, which suggests that health care seeking is a rational behavior, legislators miss less rational components, such as cultural considerations, which may factor heavily into the decision making process. Therefore, legislation targeted at reducing uninsurance without improving access may not provide the desired victory in the fight to reduce disparities and increase the health status of the population.

Affordability as a Barrier to Access
While failure to account for irrational decision making represents a potentially huge problem with the individual insurance mandate, there are, in addition, rational behaviors which may prove equally problematic. The best example of rational decision-making which could prove counter-productive to the intervention’s intent is that of teenagers and young adults affected by the health care reform laws, who may deem becoming insured unaffordable, even at the supposedly reduced costs offered by the state’s young adult plans. As discussed above, the new laws require residents eighteen and over to have their own insurance. While exceptions exist (young adults are allowed to remain on their parents’ insurance for up to two years after they lose dependent status, or until they are 26 years old), for some teens and young adults, the insurance decision could be as simple as a look at the health belief model.

The health belief model is a theory which attempts to predict how individuals will act when faced with health care decisions. The model has four components: perceived susceptibility, perceived severity, barriers to action, and benefits of action [3]. Using this model, it is possible to understand how a young adult might address the individual insurance mandate. First, teenagers and young adults generally perceive their susceptibility to health problems (that might require visits to the doctor) to be low. Ethier et al. (2003) show that even among teens engaging in high risk behaviors, perceived susceptibility to sexually transmitted diseases was, at most, low. [4] Some participants believed they had no susceptibility at all. Findings such as this one represent not just adolescent beliefs about STDs, but adolescent beliefs about health in general. Therefore, perceived susceptibility related to being uninsured is low, as is perceived severity. Adolescents worry about getting the flu, not getting cancer. Despite the very real possibility that adolescents can have potentially life-altering, expensive conditions, they do not believe it will happen.

Although perceived susceptibility and severity are low for this age bracket, perhaps this intervention could still, according to the health belief model, succeed. To do so, the barriers to obtaining insurance would have to be very low and be far outweighed by the benefits. Unfortunately, this is not likely to be the case for most young adults. The obvious barrier to obtaining insurance is cost. Despite plans to offer lower cost insurance to young adults [2], the fact remains that the cost of any insurance exceeds the cost of no insurance. While tax penalties exist for those who are not insured, the maximum penalty (beginning in 2008) will be equal to half the cost of the lowest Commonwealth Care plan available to a resident [1]. Therefore, for a person, such as a young adult, with low-to-no perceived susceptibility, the cost of obtaining health insurance would not be worthwhile. Therefore, on the basis of the health belief model, it is likely that many young adults will fail to obtain coverage, despite the individual mandate. Despite their uninsured status, this group is likely to remain one of the healthiest groups in the state based on age alone, thus refuting the idea that insurance status is a direct predictor of health outcomes. However, it is impossible to test this hypothesis in the current environment, where access to insurance is tightly linked to cost and ability to pay.

Cultural Competence as a Barrier to Access
Another barrier to obtaining medical care is cultural; mandating insurance does not improve outcomes for people who do not receive needed medical care due to a lack of cultural competence. For example, in her book The Spirit Catches You and You Fall Down, Anne Fadiman (1998) chronicles the story of an epileptic child of first-generation Hmong immigrants [5]. The child’s care is hampered from the very beginning, when the hospital she is taken to has no Hmong interpreter, despite the town’s large and growing Hmong immigrant population. After a series of missteps and misunderstandings which result in catastrophe, the parents, and by extension much of their community, are permanently wary of modern American medicine and no longer visit doctors or hospitals, despite the fact that they are insured by Medicaid. Situations like this one raise the question, then, of whether having insurance is enough to improve health outcomes for underserved immigrant and minority populations. In their review of cultural competency methods and models, Brach and Fraser (2000) define important techniques necessary for providing culturally competent care. These include interpreter services (notably absent in the example above), coordination with traditional healers, and promoting health in a culturally competent way, [6] which will be the focus of the next section.

In their section on culturally competent health promotion, Brach and Fraser (2000), suggest that “public information campaigns can be conducted… in the community. In an attempt to make health-promotion efforts more culturally competent, culture-specific attitudes and values have been incorporated into messages and materials” (pg.187) [6]. In essence, the authors suggest that health-care professionals use advertising theory to “sell” health care to underserved immigrant and minority populations. By doing so, they will not only increase insurance levels in these communities, but may begin to improve outcomes and health status as well. Sadly, the individual insurance mandate fails to adequately address this important issue, as described in the example below.

One example of a failure to “sell” insurance in a culturally competent way involves spoken language. The state’s new mechanism for enrolling uninsured residents in health care, the Commonwealth Connector [7], provides colorful, easy-to-use, interactive tools with information on accessing health insurance – in English. There is one page available in Spanish, but you cannot access any of the tools or other features accessible in English. According to the U.S. Census Bureau (2000), in 2000 18.7% of MA residents spoke a language other than English; of these, only 6.2% were Spanish or Spanish Creole speakers [8]. Although it is important to mention that Latinos are the minority group most likely to be uninsured, with nearly 1/3 uninsured in 1997 [9], this still leaves more than 12% of people, many of whom are from other immigrant groups, with no services easily accessible in their own language. Lu and Matani (2001) show that immigrants have very high rates of uninsurance; among people with incomes below 200% of the federal poverty level (FPL), nationally 58.2% of noncitizen immigrants and 41.6% of naturalized citizens have no insurance [10]. Since services are available only in English and a limited amount of Spanish, the Connector may not reach their target demographic. If, instead, the Commonwealth ran targeted, non-English ad campaigns in areas with high concentrations of underserved (and uninsured) immigrants, they could use the core ideas of advertising theory to “sell” insurance to these groups, which would give these underserved populations a chance at improved access to insurance and perhaps, eventually, better health status.

Unfortunately, even if they are able to reach these populations, insurance alone may not be enough to change health status and promote positive health outcomes. If there is not access to culturally competent care for the newly insured, they may continue to experience delays in care-seeking and, ultimately, poorer health outcomes. For example, one problem that stems from a lack of cultural understanding regards traditional healing methods. For many immigrant groups, traditional healing methods are believed to be effective means of maintaining health and curing disease. In most cases, there is no harm in these traditional beliefs, and in some cases they may help the patient, often through the sense of empowerment gained from being in control of their own care [11]. Should the newly insured visit health care providers and encounter antipathy to their traditional beliefs, they may decide not to come back for further treatment and care; after hearing of these problems, some may choose never to be seen at all. Without physicians actively pursuing cultural competence in these communities, it is highly probable that being insured rather than uninsured will not lead to significantly improved health outcomes. Without insurance information available in many languages, we may never have the opportunity to find out; once this change is made, increasing access to culturally competent care may, as the state hopes, cause the newly insured to have improved health status and outcomes.

Community Infrastructure as a Barrier to Access
While monetary and cultural competence issues are likely to cause the individual insurance mandate to fail at improving health outcomes, arguably the greatest shortcoming of this plan is that it does not address structural and community access issues. Access to care is defined by the Institutes of Medicine as “’the timely use of personal health services to achieve the best possible outcomes’” [12]. It stands to reason, then, that access, and thereby the best possible outcomes, cannot be achieved if “personal health services” (primary care, available appointments, specialty care, etc.) are not readily available. Though access is a problem of far greater magnitude for the uninsured, it is also an important issue for the insured, with 21% of insured people reporting access problems in a 1996 study by the Center for Health Systems Change [11]. Since access has been repeatedly linked to racial, ethnic, and socioeconomic disparities [13], it is likely that many insured people who reported access problems were members of underserved populations, suggesting that while insurance may help improve outcomes for some people, it will be far from achieving this goal for everyone. In addition, focus should be on increasing access to care, especially by increasing availability of primary care.

In the modern era, health care behaviors from the provider standpoint are often driven by reimbursement [14]. This presents a potential problem for residents, newly insured under mandates, whose insurance is provided by Medicaid HMOs (under the MA plan, this would be those newly insured who are insured through Commonwealth Care). Since Medicaid historically reimburses at lower rates than private insurance, and Medicaid HMOs plan to reimburse at approximately the same rates as fee-for-service Medicaid plans [15], there may be a lack of primary care physicians willing to accept Medicaid patients. This will make it much more difficult for these patients, despite insurance, to find a medical home and improve their health outcomes. Since Sox et al. (1998) established that having a regular physician is a more important predictor of health care access than having insurance [16], this problem needs to be solved before improved health outcomes can reasonably be expected from the insurance mandate.

Had the planners of this intervention looked at health insurance and health status through the lens of the transtheoretical model, they might have planned a somewhat different solution. The transtheoretical model suggests that there are stages in the process of behavior change, and that you must overcome each step in order to proceed to the next one [17]. When using this model to address the problems of insurance and health care utilization, one can see that for the behavior change of seeking needed medical care, an uninsured person could conceivably make it through all the stages up to preparation, the stage at which they would likely need to obtain insurance (in preparation for seeking health care from a provider). However, if they were then unable to find a doctor willing to accept their insurance, or if the waiting time for an appointment was too long, these people might never get to the “action” stage where they actually see the provider and address their health needs. To take the reality into account, steps must be taken to improve accessibility of providers and appointments, especially in rural (which have a high prevalence of inadequate structural resources [18]) and other underserved areas. Once structural access is improved, the newly insured can move through the transtheoretical model beyond preparation, to action and maintenance. Only at this point is it likely that becoming insured will lead to improved health status.

Massachusetts has recently pioneered the individual insurance mandate, a plan they hope will improve the overall health status of their residents. Unfortunately, that dream is unlikely to become a reality without modifications both to the plan and to the state’s health care infrastructure. Ultimately, the nation should go to a system of national health care under which all systems have equal access to equal health care. Since that is not a possibility currently on the horizon, Massachusetts should work on improving access to health care in the domains of affordability, cultural competence, and structural access, thereby eliminating barriers to care-seeking behavior and solidifying the link between insurance status and health status. Once these access issues are resolved, the individual insurance mandate may indeed become an excellent tool for improving the health of the Commonwealth.

1. Massachusetts Department of Health Care Finance and Policy (MDHCFP). Draft TIR 07-18: Individual mandate penalties for tax year 2008. 2008.
2. McDonough, J.E., et al. The Third Wave Of Massachusetts Health Care Access Reform. Health Affairs, 2006; 25(6): 420-431.
3. Strecher, V. and I. Rosenstock. The health belief model (p. 113 - 116). In: Baum, A, ed. Cambridge Handbook of Psychology, Health, and Medicine. Cambridge: Cambridge University Press, 1997.
4. Ethier, K.A., et al. Adolescent women underestimate their susceptibility to sexually transmitted infections. Sex Transm Infect, 2003; 79(5): 408-411.
5. Fadiman, A. The Spirit Catches You and You Fall Down: A Hmong child, her American doctors, and the collision of two cultures. United States: Farrar, Strauss, and Giroux, 1998.
6. Brach, C. and I. Fraser. Can Cultural Competency Reduce Racial And Ethnic Health Disparities? A Review And Conceptual Model. Med Care Res Rev, 2000; 57(suppl 1): 181-217.
7. Commonwealth Connector. Commonwealth Connector: You need insurance. The state's health connector can help. Boston: Commonwealth Connector.
8. United States Census Bureau. Langauge Spoken at Home: 2000. Census 2000 Summary File -- Sample data 2000 [cited; Available from:
9. Brown, E., et al. Racial and ethnic disparities in access to health insurance and health care, in Policy Research Reports. 2000, UCLA Center for Health Policy Research: Los Angeles, CA.
10. Ku, L. and S. Matani. Left Out: Immigrants' Access To Health Care And Insurance. Health Affairs, 2001; 20(1): 247-256.
11. Lewith, G. Complementary and alternative medicine: an educational, additudinal, and research challenge. Med Jour Aust, 2000; 172(3): 102-103.
12. Andrulis, D.P. Access to Care Is the Centerpiece in the Elimination of Socioeconomic Disparities in Health. Ann Intern Med, 1998; 129(5): 412-416.
13. Ibrahim, S.A., S.B. Thomas, and M.J. Fine. Achieving Health Equity: An Incremental Journey. Am J Public Health, 2003; 93(10): 1619-1621.
14. Armour, B.S., et al. The effect of explicit financial incentives on physician behavior. Arch Intern Med, 2001; 161(10): 1261-1266.
15. Holahan, J., et al. Medicaid managed care in thirteen states. Health Affairs, 1998; 17(3): 43-63.
16. Sox, C.M., et al. Insurance or a regular physician: which is the most powerful predictor of health care? Am J Public Health, 1998; 88(3): 364-370.
17. Edberg, M. Essentials of health behavior: Social and behavioral theory in public health. Boston: Jones and Bartlett Publishers, 2007.
18. Hayward, R.A., et al. Regular source of ambulatory care and access to health services. Am J Public Health, 1991; 81(4): 434-438.

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  • At April 24, 2008 at 1:23 AM , Anonymous Ting said...

    If affordability of care is the strongest predictor for seeking care and insurance is the best way to ensure affordability, shouldn't the first step, regardless of the downstream system, be to mandate that everyone has the ability to pay for care even if they choose not to seek it out or are unable to seek it out?

    Perhaps an additional criticsm should be that even for those who purchase it, the mandated insurance provides inadequate coverage and high copays.


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